Isr J Psychiatry Relat Sci - Vol. 49 - No 4 (2012) Paraphilic Diagnoses in DSM-5 Richard B. Krueger, MD, and Meg S. Kaplan, PhD Columbia University, College of Physicians & Surgeons, Department of Psychiatry, and Sexual Behavior Clinic, New York State Psychiatric Institute, New York, New York, U.S.A. scheduled for publication in May of 2013 (2). Major changes are being proposed for both the specific criteria ABSTRACT and for the overall organizational structure of The Background: The DSM-5 has been under revision since Diagnostic and Statistical Manual of Mental Disorders 1999 and is scheduled for publication in 2013. This article (1, 3) . The paraphilias are no exception to these changes will review the major proposed modifications of the (4). Significant controversy has surrounded both the Paraphilias. DSM-5 (5) and its proposed revisions for paraphilic diagnoses (6). This article will review the major revi- Method: The information reviewed was obtained from sions proposed for the paraphilic disorders as well as PubMed, PsychInfo, the DSM-5.org website and other some of the significant criticisms. sources and reviewed. Results: Pedohebephilia, Hypersexual Disorder and Paraphilic Coercive Disorder are new proposed diagnoses. METHOD Paraphilias have been assigned their own chapter in DSM- A literature search was conducted on PubMed and 5 and a distinction has been made between Paraphilias PsychoInfo databases from the year 1990 through April and Paraphilic Disorders. Victim numbers have been of 2011. The search used search terms of “paraphilias,” included in diagnosis of paraphilias that involve victims “exhibitionism,” “voyeurism,” “frotteurism,” “sadism,” and remission and severity measures have been added “masochism,” “fetishism,” “transvestic fetishism,” “para- to all paraphilias. Transvestic Disorder can apply to males philia-related disorder,” “hypersexual,” “hypersexuality,” or females, Fetishistic Disorder now includes partialism, “sexual addiction,” “sexual compulsion,” “paraphilic and Sexual Masochism Disorder has Asphyxiophilia as coercive disorder,” “hebephilia,” “pedophilia,” and “para- a specifier. philic rape.” Titles and/or abstracts were inspected to ascertain if the article contained criticisms relevant Limitations: This study is based on a literature review and to the current DSM-5. Relevance was ascertained by influenced by the knowledge and biases of the authors. any mention of any of the Diagnostic Manuals, or by Conclusions: The Paraphilic Disorders Section of the reference to criticism or diagnostic criteria in their title DSM-5 represents a significant departure from DSM- and/or abstracts. In addition, the authors drew upon, in IV-TR. an unsystematic way, secondary references, textbooks, textbook chapters, and newspaper articles that com- mented on the DSM or DSM-5. Finally, the DSM-5. org website was consulted extensively. Inevitably, the selection of articles was influenced by the experience BACKGROUND and biases of the authors, but an attempt was made The revision of The Diagnostic and Statistical Manual to present both positive and negative criticism on the of Mental Disorders began in 1999 (1) and DSM-5 is major issues in a balanced way. Address for Correspondence: Richard B. Krueger, MD, Medical Director, Sexual Behavior Clinic, New York State Psychiatric Institute, 1051 Riverside Drive, Unit #45, New York, New York 10032, U.S.A. [email protected] 248 RICHARD B. KRUEGER AND MEG S. KAPLAN RESULTS First (10) opined that this distinction “has strong conceptual and practical advantages” (p. 250). Wakefield Proposed Changes Affecting All or Several of the (12) referred to this as a “welcome but more a termi- Paraphilias nological revision rather than an actual change in the criteria” (p. 203) and noted that this distinction had 1. ProPOSED SEpaRATE CaTEGORIZATION FOR THE been implicitly recognized since DSM-III-R. PARAPHILIAS Others have been more critical. Moser, writing A significant proposed change is that the diagnostic about the non-criminal paraphilias (13), suggested category of Paraphilias has been moved from within that “ascertainment” would not prevent misuse of these the section of Sexual and Gender Identity Disorders paraphilic diagnostic categories, and the impression in DSM-IV-TR to its own separate section, coequal that one had been “diagnosed” with such a paraphilia. with other disorders. Two new diagnoses, Paraphilic Fedoroff (14) wrote that if an ascertained paraphilic Coercive Disorder and Hypersexual Disorder, have interest was not causing any dysfunction, then it was been proposed for consideration for inclusion in the not a mental disorder and should not be contained in appendix (4, 7). the DSM at all. Further, he wrote that once a person’s paraphilic interest was ascertained, it would be difficult 2. PARAPHILIAS VS. PARAPHILIC DISORDERS to imagine that he would not be considered as being A second change that affects all of the paraphilias is diagnosed. O’Donohue (15) questioned the meaning the distinction between paraphilias and paraphilic and implications of the term “ascertained” and said that disorders. A paraphilia (8) corresponds to the A criteria, its use doubled the psychometric problems of the DSM which define an atypical or deviant sexual interest, and because it would now have to ask questions about the would be “ascertained” according to the A criteria. reliability and validity not only of diagnosis, but also However, to qualify for a diagnosis, the B criteria, which of ascertainment. specify clinically significant distress or impairment, or, in the case of paraphilias which involve a victim 3. VICTIM NUMBER (exhibitionism, frotteurism, pedophilia, sexual sadism The Paraphilias Subworkgroup suggested another broad and voyeurism) also include a specification that a person change; this involved including a specific victim number has acted on these sexual urges with a nonconsenting in the B criteria for those disorders involving noncon- individual, must in addition be fulfilled. senting persons. Several rationales were given (8). One Blanchard argued that this distinction would be was that since the majority of patients evaluated were useful to researchers in that “It would prevent a para- referred after a criminal offense they were not reliable philia from becoming invisible to clinical science just historians. A reliance on a specific victim number, because it lacks any secondary effect of disturbing the contained in criminal records, would lessen the depen- individual or others” (9, p. 307). Thus, researchers dence on self-report of urges and fantasies. A second could contemplate epidemiological studies of alterna- rationale was that the words “recurrent” and “intense” in tive sexual interest patterns using the DSM-5 A criteria the DSM-IV-TR A criteria had been criticized as being without the necessity that these would be disorders. too vague to be useful (16) and requiring a minimum Further, this new conceptualization addresses some number of victims would increase the certitude in of the concerns raised by groups advocating for those diagnosing these disorders in non-cooperative patients. with paraphilic sexual interests, such as the National This reliance on victim count has been vigorously Coalition for Sexual Freedom, who demand that para- criticized, especially in light of the requirements for data philias be removed entirely from the DSM because their set forth as a precondition for criterion change in the inclusion is stigmatizing, by listing these non-disordered DSM, which require, for a substantial change, that there paraphilias in the “Other Conditions That May Be a be a broad consensus of expert clinical opinion, that Focus of Clinical Attention” chapter of DSM-5 (10). there be empirical support from a number of validators, Indeed Wright (11) described a child custody case in and that such change should not be based solely on which the proposed revisions for DSM-5 were cited and reports from a single researcher or research team (17). a mother, involved with sexual sadism, was allowed to First (18) reviewed the proposals for including a specific keep her children. victim count, and found that for all of the disorders, 249 PARAPHILIC DIAGNOSES IN DSM-5 only a single study (20) was cited as justification for of a paraphilia and these scales offer a significant step adopting a diagnostic threshold involving victims. towards providing such scales. Another line of criticism against victim number has been that a requirement for a minimum number of victims would result in false negatives. In the case PROPOSED CHANGES AFFECTING SPECIFIC of Pedohebophilia, for instance, an individual who PARAPHILIAS had abused only one child for at least 6 months would not necessarily make criteria for this diagnosis under 1. PedohebePHILIC DISORDER DSM-5 (15). O’Donohue (15) also raised the question Perhaps the most controversial of the proposed para- of why the unit of analysis was the victim, as opposed philic diagnoses in DSM-5 concerns Pedophilia. The to the number of abusive incidents. On the other hand, Paraphilias Subworkgroup has recommended renaming Wakefield (12) expressed that setting such a thresh- Pedophilia to Pedohebephilic Disorder and expanding old was a positive step against making false positive its definition to include hebephilia, which is a sexual diagnoses. desire for early pubescent children. In DSM-IV-TR, Pedophilia referred to an interest only in a prepubescent 4. REMISSION child or children, and the proposed revision for DSM-5 The term “In Remission”